Dropped by my provider today to pick up some records and prominently displayed was a sign that said they will NO Longer accept Exchange insurance for any of their services. This is one of the mega clinics of late, where they have assimilated almost all of the local doctors practicing medicine in this field (Oncology). They had some gibberish about they were sorry for any inconvenience to their patients but this was their decision. So should you wade through the sign up fiasco and pay your premiums (subsidized or not), you still cannot use it to go to the doctor. My admittedly brief survey determined that about 65% of the doctors practicing in this metropolis (DFW) are part of this group that won't take the exchange insurance. And they were the low cost providers at least as far as my portion of co-pay after my previous insurance paid their amount.
I don't hear anything from Obama and crowd about this very real issue, in fact, if I recall correctly, they said this would never happen.
Appears the truth is not what they told us.

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So who out there knows how PPO networks work. If a group of doctors participate in BCBS generally, can they refuse a specific BCBS contract (e.g. refuse Federal but accept corporate, refuse BCBS Exchange but accept Federal and corporate)? I thought you could go to a BCBS participating doctor with any BCBS insurance and they have to accept you.

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Many insurance plans on the exchange share the same network or network tiers used for their group plans. Certainly Blue Cross, Humana and Aetna are in this group. Providers don't know (or care) where or how the policy was sold.

Insurers constructed their networks with providers and hospitals who would accept their negotiated rates. In 5 of the 7 cases, insurers did not contract with a major children's hospital because the hospital refused to accept the rates.

Yesterday that hospital asked the Insurance Commissioner to review the adequacy of each insurer's network. Oh, and by the way, they are in discussions with several insurers to become part of their network.

So, the FIRST moral of the story is that when a business entity discovers their stream of income won't continue, they re-consider their refusal of the initial payment.

The SECOND moral of the story is that Obamacare has nothing to do with it. This is the way that insurers and specialty practices/hospitals negotiate. At the end they come to an agreement. In the interim, patients lose access to care, but generally not for very long.

The SECOND moral of the story is that Obamacare has nothing to do with it. This is the way that insurers and specialty practices/hospitals negotiate. At the end they come to an agreement. In the interim, patients lose access to care, but generally not for very long.

The more things change, the more they stay the same.

-- Rita

Very true. In my state the major insurance carrier is fighting with the major hospital chain, over money, not about patient care or quality service. They dropped the hospitals and huge chunk of the market is affected.

One buddy that works for a small company has changed networks 5 times in the last 5 years as his employer went shopping for the cheapest price. Each time they had find new docs, even went back to one they had before because of the network change.

Experience in Washington state: Insurers constructed their networks with providers and hospitals who would accept their negotiated rates. In 5 of the 7 cases, insurers did not contract with a major children's hospital because the hospital refused to accept the rates. Yesterday that hospital asked the Insurance Commissioner to review the adequacy of each insurer's network. Oh, and by the way, they are in discussions with several insurers to become part of their network. So, the FIRST moral of the story is that when a business entity discovers their stream of income won't continue, they re-consider their refusal of the initial payment. The SECOND moral of the story is that Obamacare has nothing to do with it. This is the way that insurers and specialty practices/hospitals negotiate. At the end they come to an agreement. In the interim, patients lose access to care, but generally not for very long. The more things change, the more they stay the same. -- Rita

Rita, your explanations are always clear and helpful. Thank you!

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That's interesting if it's true that Insurers are pushing for more cuts to the rates they pay providers.

In all the health care reform discussions, there hasn't been as much attention paid to what providers charge, which can vary a lot even within the same city.

And generally, American hospitals charge a lot more than in other countries.

There's been a lot of talk about insurance companies jacking up premiums and such. But the profits that insurers earn is just a drop in the bucket compared to overall healthcare spending of $3 trillion a year.

Hospitals and other providers probably have a much bigger piece of the pie.

So who out there knows how PPO networks work. If a group of doctors participate in BCBS generally, can they refuse a specific BCBS contract (e.g. refuse Federal but accept corporate, refuse BCBS Exchange but accept Federal and corporate)? I thought you could go to a BCBS participating doctor with any BCBS insurance and they have to accept you.

Generally, yes. In most areas, provider groups (or facilities) can participate in all, some, or none of the specific Plans a carrier offers. But historically providers have generally accepted all of a carrier's Plans (or not). This has become an issue for BCBS Exchange Plans in my region, at least according to local press reports. If you have an Exchange Plan with BCBS your choice of providers is more limited.

Choice and network is determined by the individual policy, not the insurer. In most states BCBS is offering plans that have lower cost restricted networks alongside more expensive plans that have expansive networks, and people are free to choose. In 30 states, including California, it is offering multi-state plans that have been negotiated with OMP.

Many insurance plans on the exchange share the same network or network tiers used for their group plans. Certainly Blue Cross, Humana and Aetna are in this group. Providers don't know (or care) where or how the policy was sold.

Exactly! The policy that I'm looking at on the exchange is also sold directly by the insurer on their website. I looked because I was curious about pricing on and off the exchange (which un-subsidized was nearly identical). The policy could also be purchased through an insurance broker in our state.

So how would a provider know where I purchased it and why would they care, it's the same policy?

Dropped by my provider today to pick up some records and prominently displayed was a sign that said they will NO Longer accept Exchange insurance for any of their services. This is one of the mega clinics of late, where they have assimilated almost all of the local doctors practicing medicine in this field (Oncology). They had some gibberish about they were sorry for any inconvenience to their patients but this was their decision. So should you wade through the sign up fiasco and pay your premiums (subsidized or not), you still cannot use it to go to the doctor. My admittedly brief survey determined that about 65% of the doctors practicing in this metropolis (DFW) are part of this group that won't take the exchange insurance. And they were the low cost providers at least as far as my portion of co-pay after my previous insurance paid their amount.
I don't hear anything from Obama and crowd about this very real issue, in fact, if I recall correctly, they said this would never happen.
Appears the truth is not what they told us.

Wait .... In Florida, and I've seen this already, the plans being sold on the Exchange are identical to the ones that they're selling directly to the public. They have no "exchange" plans .... only plans that are separated by PPO, HMO, etc.

How would a physician who accepts, for example in Florida, know the difference between a "Blue Care" insurance plan acquired through the Exchange as opposed to the same "Blue Care" insurance plan acquired directly from Blue Cross?

Unless I'm missing something important here, that makes no sense.

(I know that MANY physicians are dropping from "government plans" such as Medicare, Medicaid, and the plethora of different options out there .... but that's entirely different from "exchange acquired" plans).

Besides not being able to tell the difference between a policy purchased through the exchange and one acquired elsewhere, I think there is another oddity here.

As far as I am aware, one was only able to begin signing up to purchase health insurance through an exchange on October 1st. The actual date any policy would be active would be no sooner than January 1st, 2014. That means that NO ONE has yet presented card from a policy purchased on the exchange to ANY health care provider.

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